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Event Notification Report for March 16, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/15/2018 - 03/16/2018

** EVENT NUMBERS **


53249 53250 53252 53261 53262 53263 53265

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Agreement State Event Number: 53249
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: ISORAY MEDICAL, INC.
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/07/2018
Notification Time: 17:09 [ET]
Event Date: 02/27/2018
Event Time: [PST]
Last Update Date: 03/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
LANCE ENGLISH (ILTA)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT- LOST AND THEN FOUND SHIPMENT

The following was received from the State of Washington via email:

"A shipment of 55 Cs-131 seeds with a total activity at the time of shipment of 10.7 GBq was lost by [common carrier] during shipment from Richland, WA to New York, NY. [Common carrier] stated to Isoray that the package went missing on 2/27/2018. The package was scanned leaving Spokane, WA but was never scanned in at the hub in Memphis, TN. The package description from the licensee is as follows: Isoray's internal order number is SCP181163. The package was 55 seeds, total apparent activity of 139 mCi, shipped as a Limited Quantity of Radioactive Material/Priority Alert Overnight. The total GBq at time of shipment was 10.7. The seeds were shipped non-sterile per the ordering M.D.'s request, they were contained in six 'Mick' cartridges inside of a stainless steel pig.

"Update on 3/7/2018: The package was found by [the common carrier] and has been returned to the Isoray facility unopened. Isoray has stored the seeds for decay."

Incident Number: WA-18-006

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53250
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HOUSTON METHODIST
Region: 4
City: HOUSTON State: TX
County:
License #: 00457
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/07/2018
Notification Time: 17:20 [ET]
Event Date: 03/02/2018
Event Time: [CST]
Last Update Date: 03/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION

The following was received from the State of Texas via email:

"On March 7, 2018 Agency [Texas Department of State Health Services] received notification that a Novoste device jammed with no exposure consequence to the patient. Licensee stated two attempts to complete the therapy procedure had taken place, there was no dose to the patient that would be classified as a medical event. The initial attempt with a beta-rail catheter was not successfully completed. The source train (16, Sr 90) did not move along the beta-rail catheter as expected, the source train was not retracted back into the device robotically. The source train in the Novoste device failed to go into the expected treatment position and stayed in the robotic interventional cardiology device for about 1.5 minutes during the intravascular brachytherapy procedure. The interventional catheter with the indicator source train was removed by the doctor (which he wasn't supposed to do). When the train could not be robotically remove back into the device through the beta rail catheter, the source removal from the patient had to be done manually. The source train was retrieved in 15 seconds and placed back into the Novoste device. The treatment was stopped. The patient was surveyed to confirm no sources in the patient. It was believed the beta catheter developed a kink and could not retract the sources. The second attempt was with a new beta rail catheter and source reset. The treatment continued without any incidents. The source returned to the device without any problems."

Incident # 9552

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Agreement State Event Number: 53252
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: WASHINGTON STATE UNIVERSITY
Region: 4
City: PULLMAN State: WA
County:
License #: WN-C003-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/08/2018
Notification Time: 10:57 [ET]
Event Date: 02/14/2018
Event Time: [PST]
Last Update Date: 03/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received via email from the state of Washington:

"On 2/15/2018, the RSO [Radiation Safety Officer] for WSU [Washington State University] contacted DOH [Washington State Department of Health] to report a leaking Cf-252 source. The source was received from University of Nevada - Reno and leak tested on arrival. The initial leak test found 0.0066 uCi of removable contamination. Because the amount of removable contamination detected was very close to the leak testing limit, WSU was asked to check their leak testing process and perform another test. On 2/27/2018, WSU confirmed that the source is in fact leaking and both tests provided the same result and that they are holding the leaking source for disposal. DOH is still awaiting further information on the source manufacturer and model number. More information will be provided in a follow-up report."

WA Incident Number: WA-18-007

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 53261
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/15/2018
Notification Time: 01:39 [ET]
Event Date: 03/14/2018
Event Time: 17:11 [CDT]
Last Update Date: 03/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JESSE ROLLINS (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF EMERGENCY NOTIFICATION TONE ALERT RADIO SYSTEM

"At approximately 1711 CDT on 14 MAR 2018, Cooper Nuclear Station was notified by the National Weather Service that the Shubert radio transmission tower was not functioning. This affects the tone alert radios used to notify the public in event of an emergency condition. This condition is reportable under I0CFR50.72(b)(3)(xiii). A backup notification method is available and will be utilized for notifications if needed.

"The local telephone company is providing troubleshooting and repair services. A return to service time for the Shubert tower is not currently available.

"The NRC Senior Resident Inspector has been informed."

The issue was identified during periodic maintenance.

The licensee notified all counties within the 10 mile Emergency Planning Zone.

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Part 21 Event Number: 53262
Rep Org: NEXTERA ENERGY - INTEGRATED SUPPLY
Licensee: NEXTERA ENERGY - INTEGRATED SUPPLY - DEDICATING ENTITY
Region: 1
City: WEST PALM BEACH State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ALBERT LAFLEUR
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/15/2018
Notification Time: 09:22 [ET]
Event Date: 01/16/2018
Event Time: [EDT]
Last Update Date: 03/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARC FERDAS (R1DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - INADEQUATE DEDICATION OF RELAYS

"On March 13, NextEra Energy completed its evaluation of a deviation concerning relays dedicated at its Corporate Procurement Engineering & Dedication Facility and concluded that the condition represented a defect under 10 CFR 21.

"The defect was discovered on January 16, 2018 during pre-installation bench testing. During that bench test, some of the relays exhibited contact chatter. Upon review of the dedication, it was identified that contact chatter had been noted at reduced voltage, and that the condition was improperly dispositioned as acceptable. That conclusion was incorrect as the relays are DC powered and may be required to operate under reduced voltage conditions.

"The affected relays were supplied to the Seabrook Nuclear Power Station. None of those relays were installed and all have been quarantined to prevent installation.

"Dedicating Entity: NextEra Energy Integrated Supply Chain - Corporate Procurement Engineering & Dedication Facility, West Palm Beach, FL

"Device: GE Relay, base model CR120BD"

NextEra expects to complete their evaluation by April 14, 2018.

For additional information please contact: Albert Lafleur, (561) 845-3343, al.lafleur@fpl.com

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Part 21 Event Number: 53263
Rep Org: ROSEMOUNT NUCLEAR
Licensee: ROSEMOUNT NUCLEAR
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DUYEN PHAM
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/15/2018
Notification Time: 10:54 [ET]
Event Date: 03/08/2018
Event Time: [CDT]
Last Update Date: 03/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARC FERDAS (R1DO)
REBECCA NEASE (R2DO)
JESSE ROLLINS (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - DEFECT REGARDING CERTAIN PRESSURE TRANSMITTERS AND AMPLIFIER CIRCUIT CARD ASSEMBLIES

The following notification is an excerpt from the received report:

"Pursuant to 10 CFR Part 21, section 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you that a total of eleven (11) Model 1154 and 1154 Series H output range code 4 pressure transmitters whose model code includes special option suffix N0026 or N0087 and five (5) 01154-0153-0002 Amplifier Circuit Card Assemblies may not calibrate at all the published values.

"Name and address of the individual providing the information:
Mr. Gerard Hanson
Vice President & General Manager
Rosemount Nuclear Instruments, Inc.
8200 Market Blvd
Chanhassen, MN 55317

"Nature of the failure and potential safety hazard: During evaluation of two returned 01154-0153-0002 Amplifier Circuit Card Assemblies (CCAs), it was observed that a single resistor (R316) on each affected Amplifier CCA had an incorrect resistance value.

"The N0026 and N0087 special options enable a standard upper range limit (URL) of a transmitter with output range code 4 to be increased from 150 inches water to 210 inches water, in combination with a minimum span of 75 inches water. This R316 resistor allows the transmitter to achieve performance specifications, calibration ranges, and spans as indicated by the special option drawing.

"In the sub-assembly process, the R316 resistor on a standard Amplifier CCA is replaced to create a new Amplifier CCA part number (01154-0153-0002). The R316 resistor enables the standard lower range limit (LRL) of a transmitter with output range code 4 to be decreased from -150 inches water to -210 inches water (negative pressure values imply pressure applied to the low-pressure side of the transmitter), in combination with a minimum span of 75 inches water. This R316 resistor allows the transmitter to achieve performance specifications, calibration ranges, and spans as indicated by the special option drawing.

"The new resistor's material traceability information is recorded on the traveler. In final assembly, each transmitter with special option suffix N0026 and N0087 is assembled using one of these 01154-0153-0002 Amplifier CCAs. It then receives a factory calibration check at 135 inches water to 210 inches water and customer specified calibrated range, to ensure conformance to the minimum span and maximum URL specifications, as defined by the special option drawing. Appropriate manufacturing paperwork is used to document and record each Amplifier CCA serial number, as well as each final assembly transmitter.

"To meet site specific application requirements, transmitters may be field recalibrated to different upper and lower range values and/or spans. Model 1154 and 1154 Series H transmitters with special option suffix N0026 or N0087 and Amplifier CCAs whose R316 resistors were not replaced during the sub-assembly process, will have incorrect resistance values and may not calibrate to all upper and lower range values and/or spans published for the applicable special option. However, if an affected transmitter has been successfully calibrated, having the incorrect resistance value will not adversely affect transmitter performance specifications during normal operation or accident conditions.

"The manufacturing records for the two returned Amplifier CCAs, part number 01154-0153-0002, were carefully reviewed. The sub-assembly traveler lacked the required material traceability information, indicating that the R318 resistors were not replaced. RNII reviewed all sub-assembly travelers for part number 01154-0153-0002. The issue has been isolated to one lot which included (16) Amplifier CCAs.

"On March 8, 2018, RNII concluded that a substantial safety hazard may exist.

"The corrective action which has been taken; the name of the individual or organization responsible for that action; and the length of time taken to complete that action:

"(a) RNII previously discontinued manufacturing 01154-0153-0002 Amplifier CCAs, there are no Amplifier CCAs currently in production or finished goods.

"(b) RNII examined all manufacturing paperwork for all 01154-0153-0002 Amplifier CCAs, and other than the single lot of (16) Amplifier CCAs described above, no additional discrepancies were found.

"Any advice related to the potential failure of the item: The end user is advised to determine the impact of this potential non-conformance on its plant operations and safety and take action as deemed necessary. Affected 01154-0153-0002 Amplifier CCA(s) and transmitter(s) can be returned to RNII for rework. Contact RNII to facilitate the return process.

"If there are any questions, or you require additional Information related to this issue, please contact: Mike Dougherty (206) 665-1112, Paul Schmeling (952) 949-5359, or Brian VanderWoude (952) 949-5207.

"Shipped as piece parts (P/N 01154-0153-0002) to Arkansas Nuclear One and Waterford.

"Shipped as part of transmitter (N0026 and N0087) to Palo Verde, St. Lucie, and Calvert Cliffs."

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Power Reactor Event Number: 53265
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BRIAN BAILEY
HQ OPS Officer: VINCE KLCO
Notification Date: 03/15/2018
Notification Time: 22:08 [ET]
Event Date: 03/15/2018
Event Time: 15:24 [EDT]
Last Update Date: 03/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MARC FERDAS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FAILURE TO MEET APPENDIX R REQUIREMENTS

"At 1524 [EDT] on Thursday, March 15, 2018, Operations was notified of a failure to meet Appendix R requirements for Peach Bottom Atomic Power Station (PBAPS) Unit 2 and Unit 3. Valves associated with the feedwater system for both units were not properly considered as Hi-Lo Pressure interface valves as required by the Appendix R program. This results in the susceptibility to a hot short condition that could open valves, diverting flow from the reactor, damage piping and prevent injection. U3 [Unit 3] Fire Safe Shutdown Credited Reactor Core Isolation Cooling (RCIC) System is affected. U2 [Unit 2] is affected by a potential leak path through the Reactor Water Cleanup system.

"This event is being reported as an occurrence of an event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety under 10 CFR 50.72(b)(3)(ii).

"The Station [PBAPS] is performing hourly fire watches for the impacted areas and is also evaluating this condition for corrective action."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 16, 2018
Friday, March 16, 2018